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Key Themes and Highlights

National Healthcare Disparities Report, 2008

Key Themes and Highlights From the National Healthcare Disparities Report

Examining health care disparities is an integral part of improving health care quality. Health care disparities are the differences or gaps in care experienced by one population compared with another population. As the National Healthcare Quality Report (NHQR) shows, Americans too often do not receive care that they need or they receive care that causes harm. The National Healthcare Disparities Report (NHDR) shows that moreover, some Americans receive even worse care than other Americans. The quality of health care is different for different people. Within the scope of health care delivery, these disparities are due to differences in access to care, provider biases, poor provider-patient communication, poor health literacy, and other factors.

The purpose of the NHDR, as mandated by Congress,i is to identify the differences or gaps where some populations receive poor or worse care than others and to track how these gaps are changing over time. Although the emphasis is on disparities related to race, ethnicity, and socioeconomic status, this directive also includes a charge to examine disparities in "priority populations." These include groups with unique health care needs or issues that require special attention. Among the priority populations addressed in the NHDR are women, children, older adults, residents of rural areas, and individuals with disabilities or special health care needs.

The NHDR uses the same 220 measures used in the NHQR categorized across four dimensions of quality: effectiveness, patient safety, timeliness, and patient centeredness. This year's report focuses on the state of health care disparities for a group of 45 core measuresii that represent the most important and scientifically credible measures of health care quality for the Nation, as selected by the Department of Health and Human Services (HHS) Interagency Work Group.iii By focusing on core measures, the 2008 report provides a more readily understandable summary and explanation of the key results derived from the data.iv While the measures selected for inclusion in the NHDR are derived from the most current scientific knowledge, this knowledge base is not evenly distributed across the dimensions of health care quality, nor across racial, ethnic, and other priority populations. The analysis in the following pages centers on measures for which data are available and that fit within the framework provided by the Institute of Medicine.1

Three key themes emerge in the 2008 NHDR:

Disparities persist in health care quality and access.

Magnitude and pattern of disparities are different within subpopulations.

Some disparities exist across multiple priority populations.

i This 2008 report is the sixth National Healthcare Disparities Report (NHDR) mandated by the U.S. Congress (42 U.S.C. 299a1(a)(6)). It is produced by the Agency for Healthcare Research and Quality (AHRQ) on behalf of the U.S. Department of Health and Human Services (HHS) and in collaboration with an HHS-wide Interagency Work Group.ii Not all core measures have data for all subgroups for analyses.iii The HHS Interagency Work Group, which represents 18 HHS agencies and offices, was formed to provide advice and support to AHRQ and the National Reports team.iv Data on all NHDR measures are available in the Data Tables appendix at http://www.ahrq.gov/qual/measurix.htm.

Disparities Persist in Health Care Quality and Access

All population groups should receive equally high quality of care. Getting into the health care system (access to care) and receiving appropriate health care in time for the services to be effective (quality of care) are key factors in ensuring good health outcomes.

Both categories of measures, quality of care and access to care, show that disparities persist for all populations. Measures of quality include effectiveness (the percentage of patients with a disease or condition who get recommended care), patient safety, and timeliness. The NHDR includes the added dimension of access to care to measure differences in health insurance coverage, utilization of general health services, and other barriers to care. Below are figures that illustrate for each population how disparities in quality and access have changed in the past 5 years.

Figure H.1 shows that for Blacks, Asians, American Indians/Alaska Natives (AI/ANs), Hispanics, and poor people, at least 60% of measures of quality of care are not improving (either stayed the same or worsened).

Figure H.1. Change over time in racial, ethnic, and socioeconomic disparities for selected core quality measures, 2000-2001 to 2005-2006

Improving = Population-reference group difference becoming smaller at an average annual rate of greater than or equal to 1%.Same = Population-reference group difference changing at less than an average annual rate of 1%.Worsening = Population-reference group difference becoming larger at an average annual rate of greater than or equal to 1%.Key: AI/AN = American Indian or Alaska Native.Note: "Asian" includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available. Measures presented here for racial and ethnic minority groups are a subset of the core measure set that has data for all groups. Some measures for poor populations are different from the measures used for racial and ethnic groups.

Many Americans have access to primary and hospital care. For many populations, however, barriers exist to getting needed health care, such as having no health insurance or having trouble getting appointments. Reducing disparities in access to health care is an important step to improving overall quality.

For AI/ANs, 75% of the core measures that could be tracked over time improved (gap decreased).

For Blacks and Asians, 60% of the core measures used to track access remained unchanged (gap stayed the same) or got worse (gap increased).

For Hispanics, 80% of core access measures remained unchanged or got worse.

For poor populations, 57% of core access measures remained unchanged or got worse.

Figure H.2. Change over time in racial, ethnic, and socioeconomic disparities for selected core access measures, 2000-2001 to 2005-2006

Improving = Population-reference group difference becoming smaller at an average annual rate of greater than or equal to 1%.Same = Population-reference group difference changing at less than an average annual rate of 1%.Worsening = Population-reference group difference becoming larger at an average annual rate of greater than or equal to 1%.Key: AI/AN = American Indian or Alaska Native.Note: "Asian" includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available.

For AI/ANs, 75% of the core measures that could be tracked over time improved (gap decreased).

For Blacks and Asians, 60% of the core measures used to track access remained unchanged (gap stayed the same) or got worse (gap increased).

For Hispanics, 80% of core access measures remained unchanged or got worse.

For poor populations, 57% of core access measures remained unchanged or got worse.

Making Patient's and Families' Lives Better

Providing data through the NHDR is only one of many efforts to reduce health care disparities in the United States. As multiple individual, community, social, and health system factors contribute to health care disparities, multiple strategies exist to address these factors. Efforts have focused on training health care professionals, raising awareness among health professionals and patients, and changing health systems at the hospital, provider, and community level.

The Think Cultural Health Web site (http://www.thinkculturalhealth.org ) is sponsored by the Office of Minority Health (OMH). This Web site offers the latest resources and tools to promote cultural competency in health care. Users can access free online courses accredited for continuing education credit. The site also provides supplementary tools to help providers and organizations promote respectful, understandable, and effective care to an increasingly diverse patient population. This Web site provides access to online courses such as "A Physician's Practical Guide to Culturally Competent Care" and "Culturally Competent Nursing Care," as well as interactive tools such as the "Health Care Language Services Implementation Guide."

The Unified Health Communication Web-Based Training Program is sponsored by the Health Resources and Services Administration (HRSA). This interactive Web-based training course introduces a unified health communication concept called "Unified Health Communication (UHC) 100/101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency." The UHC 100/101 course explores three crucial areas that can affect provider-patient communication: health literacy, cultural competency, and limited English proficiency. Each of these three components can influence various aspects of health communication. In combination, they can have an even greater impact on improving health care delivery, reducing health disparities, and empowering patients to become more involved in their own health management to enhance their quality of life. This course is currently used across a variety of health care delivery venues. Its use underscores the importance of clear health communication through the discussion of innovative approaches by health care providers.

The Office for Civil Rights (OCR) is the sole HHS agency with the authority to enforce Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d. This law prohibits discrimination based on race, color, or national origin in programs and activities that receive Federal financial assistance, including most health care providers and human service agencies. OCR's Title VI enforcement activities aim to decrease health disparities by increasing access to health care and human services. OCR enforces Title VI by investigating race, color, and national origin discrimination complaints filed by individuals and advocacy groups; and by resolving those complaints through voluntary compliance agreements and corrective action monitoring. OCR, for example, recently entered into a voluntary compliance agreement with the Hawaii Department of Human Services (DHS), which administers a $1.7 billion annual budget, including the State's Medicaid, health, and longterm care programs. To comply with Title VI, Hawaii DHS has agreed to improve language assistance services for limited-English-proficient individuals, including translating vital documents and providing timely, competent interpreters.

Other efforts to address health care disparities leverage key partnerships to raise awareness of disparities by using data and research:

The Health Disparities Roundtable was convened in 2006 under cosponsorship by OMH and AHRQ and in partnership with the Institute of Medicine (IOM). The purpose of the IOM roundtable is to generate action and engage interested parties from academia, industry, government, philanthropy, the corporate sector, and the community to reduce racial and ethnic health disparities. It fills an important role as a focus for public-private partnerships on research and policy discussions to address various topics. These include ways to bring together health care-focused and broader community-based approaches to address disparities more effectively; strategies to expand and strengthen research to develop effective treatments for those diseases that disproportionately affect minority populations, as well as research that focuses on the complex interactions of biologic and social factors as determinants of health; effective cultural competency techniques and cross-cultural education in health care settings; educational strategies to end health disparities; development and promotion of effective strategies to increase minority representation in medicine and health professions; and understanding of the causes of health and health care disparities and best solutions.

The Federal Collaboration on Health Disparities Research (FCHDR) was developed by the Centers for Disease Control and Prevention (CDC) in collaboration with OMH and cosponsored by AHRQ. FCHDR was developed to identify and support research priorities for cross-agency collaboration to hasten the elimination of health disparities. This collaboration is led by the HHS Health Disparities Council and the Interagency Committee on Disability Research of the Department of Education. Through FCHDR, Federal partners have formed subject matter expert workgroups around four initial research topic areas for collaboration: obesity, built environment (homes, schools, workplaces, parks and recreation areas, business areas, transportation systems, etc.), mental health care, and comorbidities. These priorities represent opportunities for Federal agencies and other partners to collaborate on innovative research.

The Disparity Reducing Advances Project is a multiyear, multistakeholder project cosponsored by AHRQ and others, including CDC, the National Cancer Institute, the American Cancer Society, a Florida hospital agency, the Robert Wood Johnson Foundation, and the University of Texas Medical Branch. This project identifies the most promising strategies for bringing health gains to poor and underserved populations and accelerating the development and deployment of these strategies to reduce health care disparities.

The Centers for Medicare & Medicaid Services (CMS) Health Disparities Program allows CMS to develop a health care forum that encompasses public and private partnerships to address health disparities nationwide through a common message. The focus of this program is to improve health literacy and outcomes through three overarching functions: (1) align CMS and Federal resources to provide a solid foundation for messaging on health disparities activities and projects; (2) standardize elements throughout the Quality Improvement Organization 9th Statement of Work themes for the health disparities program; and (3) work with internal and external stakeholders to advance health disparities planning objectives. The Health Disparities Program is achieving these goals by using several methods such as grants to Historically Black Colleges and Universities and Hispanic Serving Institutions, health disparities forums, newsletters throughout statewide programs, plenary sessions at conferences, and collaborations with national organizations such as the Administration on Aging, OMH, and National Institutes of Health.

Healthy People 2010 is a comprehensive health promotion and disease prevention agenda. It has two overarching goals: (1) to increase life expectancy and improve quality of life, and (2) to eliminate health disparities among population subgroups based on characteristics such as race and ethnicity, gender, and income. Through a national consensus process, HHS identified specific objectives for improving the health of the Nation, established baseline values for the objectives, and set specific targets to be achieved by 2010. The Nation's Public Health Service agencies and agencies in other Federal departments are involved in pursuing this agenda. Progress toward the achievement of these goals and objectives is monitored by CDC's National Center for Health Statistics.

AHRQ is a partner in the National Business Group on Health (NBGH) Racial and Ethnic Health Disparities Advisory Board, an initiative of NBGH and OMH to reduce racial and ethnic health disparities. Some employers have already developed initiatives to reduce health disparities. The Disparities Advisory Board will facilitate alliances between business, medicine, and public health organizations to improve the quality of health care for racial and ethnic minority populations, while promoting beneficiary health and employee productivity. Products include an issue brief on why companies are making health disparities their business, including practical strategies and a Webinar to feature best practices. The brief will be distributed to NBGH members.

Other partnerships leverage both public and private partners to address health care disparities at the community and provider level:

The AHRQ National Health Plan Collaborative (NHPC), which has 11 participating health plans with a total of 87 million enrollees, is cofunded by the Robert Wood Johnson Foundation. NHPC's purpose is to identify and implement approaches to reducing racial and ethnic disparities and to improve quality among health plan enrollees. In Phase II of the collaborative, three task forces addressed primary data collection and language access and are building the business case for reducing disparities. The collaborative builds on the continued interest of health plans in reducing disparities and improving health care for minorities. Members of the collaborative have developed a toolkit that will serve as the core vehicle to share NHPC's findings and recommendations. The toolkit will be a Web-based searchable database of tools, research, statistics, case studies, and lessons learned. Users will be able to search the tool according to their needs, resulting in a personalized page of information and resources. The toolkit will enable other health plans or stakeholders to implement interventions or methods to address disparities and will provide lessons learned and best practices for reducing disparities.

An HHS pilot project, Improving Hispanic Elders' Health: Community Partnerships for Evidence-Based Solutions, is bringing together teams of local leaders from communities with large numbers of Hispanic elders to develop local plans for addressing health disparities. Teams cut across organizational boundaries and include representatives from the local area agency on aging, Hispanic community organizations, the local public health agency, aging services providers, the medical community, and health service research organizations. AHRQ, the Administration on Aging, CDC, CMS, and HRSA are assisting teams to develop coordinated strategies for improving the health and well-being of Hispanic elders. Eight communities with sizable disparities participate in this pilot project: Chicago, Illinois; Houston, Texas; Los Angeles, California; McAllen, Texas; Miami, Florida; New York, New York; San Antonio, Texas; and San Diego, California. Information from the NHDR and customized data created by AHRQ for each community have helped target interventions to specific neighborhoods in greatest need of particular services.

The National Partnership for Action (NPA) To End Health Disparities is a multilevel effort to mobilize and connect individuals and organizations across the country to create a Nation free of health disparities, with quality health outcomes for all people. Through a nationwide, comprehensive, community-driven, sustained approach, NPA seeks to illuminate the compelling issues that affect health outcomes, identify action steps that partners can adopt and adapt for their target audiences, highlight promising practices that help eliminate health disparities, and promote tools, programs, and information sources for stakeholders. Strategic actions have been developed around five core objectives: increase awareness of health disparities, strengthen leadership at all levels, improve health care outcomes for racial and ethnic minorities and underserved populations and communities, improve cultural and linguistic competency in delivering health services, and coordinate and use research and outcome evaluations more effectively. Six Regional Conversations (meetings) were held to bring together local, State, Tribal, regional, and Federal experts and practitioners from the private and public sectors to lay the foundation for a cohesive strategy. The meetings resulted in the development of 10 Regional Blueprints that are forming the basis for improved coordination of regional actions related to reducing health disparities. The Regional Blueprints are informing the development of a National Blueprint based on 20 wide-reaching strategies.

Magnitude and Patterns of Disparities Differ Among Various Populations

Improvements in preventive care, chronic care, and access to care have led to the elimination of disparities for some priority populations in areas such as mammograms, smoking cessation counseling, and appropriate timing of antibiotics. At the same time, many of the largest disparities have not changed significantly. The NHDR can be used to identify the most important gaps in care as well as improvements for priority populations. The complete picture of disparities is different for each population. An analysis of each population allows targeting of resources and efforts to improve care and narrow the gaps in care for racial and ethnic minorities and poor populations.

In 2005, the NHDR reported on the biggest gaps that existed in health care quality in America for Blacks, Asians, AI/ANs, Hispanics, and poor populations. Some of the largest gaps reported in 2005 remain the largest gaps in this year's NHDR.

For Blacks, large disparities remain in new AIDS cases despite significant decreases. The proportion of new AIDS cases was 9.4 times as high for Blacks as for Whites. Hospital admissions for lower extremity amputations in patients with diabetes and lack of prenatal care for pregnant women in the first trimester are the largest disparities for Blacks observed in the 2008 NHDR.

For Asians, disparities remain in timeliness of care. Asians were more likely than Whites to not get care for illness or injury as soon as wanted.

For AI/ANs, disparities remain in prenatal care. AI/AN women were twice as likely to lack prenatal care as White women.v Also, AI/AN adults were less likely than Whites to receive colorectal cancer screening.

For Hispanics, large disparities also remain in new AIDS cases despite significant decreases. The rate of new AIDS cases was more than three times as high for Hispanics as for non-Hispanic Whites.

For poor people, disparities remain in communication with health care providers. The percentage of children whose parents reported communication problems with their health providers was nearly four times as high for poor children as for high-income children. Poor adults were also more than twice as likely not to get timely care for an illness or injury.

The "biggest gaps" are defined as those quality measures with the largest relative rates between Whites and racial and ethnic minorities and between high-income and poor individuals. For example, a relative rate of 4.0 means that this population was four times as likely as the White population to be hospitalized for pediatric asthma. This analysis is presented in Table H.1.

v The most recent data for prenatal care (2003-2005) are not comparable to previous data years due to revision of the U.S. Standard Certificate of Live Birth in 2003. Some States that have not adopted this revision are excluded. Go to the footnote for Figure 4.26. Table H.1 shows comparison between groups within each data year only.

Table H.1. Three largest disparities in quality of health care for selected groups: Measure and rate relative to reference group, 2005 NHDR versus 2008 NHDR (Measures that have the largest gaps in both the 2005 and 2008 NHDR are in italics.)

2005 NHDR

2008 NHDR

Group

Measure

Relative rate

Measure

Relative rate

Black compared with White

New AIDS cases per 100,000 population age 13 and over

10.4

New AIDS cases per 100,000 population age 13 and over

9.4

Hospital admissions for pediatric asthma per 100,000 population ages 2-17a

4.0

Hospital admissions for lower extremity amputations in patients with diabetes per 100,000 population

2.3

Emergency department visits in which patients left without being seen

1.9

Pregnant women who did not receive prenatal care in the first trimesterb

1.6

Asian compared with White

People age 18 and over with serious mental illness who did not receive mental health treatment or counseling in the past yeara

1.6

Adults who can sometimes or never get care for illness or injury as soon as wanted

2.1

Adults who can sometimes or never get care for illness or injury as soon as wanted

1.6

Children ages 2-17 who did not receive advice about physical activity

1.2

Adults age 65 and over who did not ever receive pneumococcal vaccination

1.5

Adults age 65 and over who did not ever receive pneumococcal vaccination

1.6

AI/AN compared with White

Pregnant women who did not receive prenatal care in the first trimesterb

2.1

Pregnant women who did not receive prenatal care in the first trimesterb

Adults who can sometimes or never get care for illness or injury as soon as wanted

2.3

Adults who can sometimes or never get care for illness or injury as soon as wanted

2.5

Children ages 2-17 who did not have a dental visit

2.0

Women age 40 and over who reported they did not have a mammogram in the last 2 years

2.1

a This measure was removed from the 2008 NHQR and NHDR core list.b The most recent data for prenatal care (2003-2005) are not comparable to previous data years due to revision of the U.S. Standard Certificate of Live Birth in 2003. Some States that have not adopted this revision are excluded. Go to the footnote for Figure 4.26. Table H.2 shows comparison between groups within each data year only.Note: Relative rate is used to compare one group with its reference group. It is calculated by dividing the group's estimate by the reference group's estimate. For example, the relative rate of new AIDS cases for Blacks compared with Whites is 9.4 in the 2008 NHDR. This means that Blacks have a rate that is 9.4 times as high as Whites for this measure.

While some disparities have remained the same or have gotten worse, other disparities have shown some improvement. Some findings demonstrate progress in decreasing disparities, where gaps have actually decreased.

From 2000 to 2005, for Blacks, the rate of deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue) improved (from 159.2 to 121.8; in 2005, this rate was not significantly different from Whites). The gap between Blacks and Whites decreased to the point that Blacks have better outcomes in this measure (from a relative rate of 1.1 to 0.97).

From 2000 to 2005, the percentage of Asian women age 40 and over who reported they had a mammogram within the last 2 years improved (approximately 4.36 million women received effective screening for breast cancer in 2005). The gap between AI/ANs and Whites who did not receive a mammogram decreased (from a relative rate of 1.8 to 1.0).

From 2000 to 2005, the percentage of AI/AN adult surgery patients who received appropriate timing of antibiotics improved (from 52.0% to 80.8%; in 2005, this rate was not significantly different from Whites). The gap between AI/ANs and Whites not receiving appropriate timing of antibiotics decreased (from a relative rate of 1.2 to 1.0).

From 2000 to 2005, the percentage of Hispanic children ages 3-6 who ever had their vision checked by a health provider improved (from 51.6% to 56.6%, or roughly 2.6 million Hispanic children). The gap between Hispanics and non-Hispanic Whites who did not receive a vision check decreased (from a relative rate of 1.2 to 1.1).

From 2000 to 2005, the percentage of poor adult smokers who received smoking cessation counseling while hospitalized improved (from 57.9% to 65.5%; in 2005, this rate was not significantly different from high-income patients). The gap between poor individuals and high-income individuals who did not receive smoking cessation counseling decreased (from a relative rate of 1.3 to 1.0).

In addition to highlighting important progress, decreases in disparities that have been observed identify areas from which lessons might be learned. Each racial and ethnic group showed improvements in some areas where quality of care had improved overall. However, not all improvements closed the gap between these groups and reference groups. Innovative approaches that have contributed to reductions in the magnitude of disparities in care suggest promising practices and effective policies that may also improve care in other areas.

Some Disparities Exist Across Multiple Priority Populations

In addition to the variable distribution of disparities evident across priority populations, in some cases several different populations experience the same gaps in care as other populations due to poor quality overall or populations experiencing similar barriers. The following measures included in the NHDR illustrate disparities for two or more populations:

Blacks, Asians, AI/ANs, and Hispanics all experienced disparities in the percentage of adults age 50 and over who received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test. For this measure, between 1999 and 2006, the disparity increased in all four groups (Table H.2).

For Blacks and Hispanics, disparities grew larger in the percentage of adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months.

Blacks and Asians both had worsened disparities in the receipt of pneumococcal vaccination for adults age 65 and over.

Blacks and Asians both had worsened disparities in a patient-centeredness measure of patient and provider communication.

Table H.2. Core measures that are getting worse for more than one racial and ethnic group compared with reference group

Topic

Cancer

Blacks

Asians

AI/ANs

Hispanics

Cancer

Adults age 50 and over who received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test

*

*

*

*

Mental health and substance abuse

Adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months

*

*

Respiratory diseases

Adults age 65 and over who ever received pneumococcal vaccination

*

*

Patient centeredness

Adults with poor provider-patient communication

*

*

Note: A complete table of the disparities that worsened for specific populations can be found in Chapter 4, Priority Populations.

Low rates of colorectal cancer screening and other cancer screenings may be due to cultural attitudes and patient perceptions, such as screenings are not necessary. In addition, patients may have problems paying for follow-up visits to complete screening, as well as logistical problems getting to the appointment. Similarly, pneumococcal vaccination rates may be lower for Blacks and Asians because many distrust the effectiveness of vaccines and perceive that vaccines are not necessary.

Overall, minorities may be less likely to access and use mental health services due to cultural beliefs related to mental health and the stigma of getting care for mental illnesses, language barriers, and poor access to mental health services. In addition, data for mental health care are limited. This lack of data is a challenge in measuring quality of mental health care and disparities among these populations, especially for small populations.

Patient experience of health care is another important indicator of health care quality. Minorities are more likely to experience poor provider-patient communication. Minority patients are more likely to receive care in clinics where providers face workplace challenges and have a more complex patient mix. Patient and provider interactions encompass various aspects of care, including whether patients can get appointments in a timely manner, whether they feel respected and listened to, and whether they understand their care. Poor provider-patient communication can result from a number of complex factors, including a provider's lack of familiarity with cultural norms, language barriers, a patient's low health literacy, a chaotic work environment, and a lack of time during a visit. Poor provider-patient communication can lead to inefficient care and medical errors. Addressing these health care disparities will require special attention to cultural attitudes and perceptions that affect health behaviors and patterns of health care access and utilization.

Measures that are improving for more than one population group may also provide additional insight toward understanding disparities. Areas of care where public policy has identified key practices that have broad and direct impact on populations have shown improvement in reducing the gap between populations. These include increasing the number of people with health insurance and improving provider awareness of recommended care and preventive care for specific conditions. Measures that showed reductions in disparities across more than one select group over time included the following:

Among Asians and Hispanics, children who received recommended vaccines.

Among Blacks, AI/ANs, and Hispanics, new AIDS cases.

Among Hispanics and poor populations, smokers with heart attack who received smoking cessation counseling while hospitalized.

Among Blacks, AI/ANs, Hispanics, and poor populations, people under age 65 with health insurance.

Since its initial publication in 2003, the NHDR has provided a broad and detailed examination of disparities for at-risk priority populations in U.S. health care. The ability to monitor and track changes in disparities is critical. Growing interest in public reporting for quality improvement activities continues to be an impetus to improve not only the quality of data but also the quality of care provided.

This 2008 report summarizes the many areas where little to no progress has been achieved in reducing disparities. However, it also highlights progress that is being made in key conditions that disproportionately affect priority populations. Many factors contribute to disparities in health care quality and access, and it is a major challenge to address them. Yet a number of promising programs at HHS, such as those described here, are doing just that. The activities described are only a few of the many efforts of HHS organizations that address the challenges in reducing health care disparities. Other HHS agencies are contributing in many other ways to address disparities in health service delivery, health care finance, and clinical research, in addition to both Federal and State efforts to expand access. What they have in common are the focus on multiple stakeholders and the need for tailored solutions depending on the particular disparities and populations involved. With the publication of this sixth NHDR, AHRQ stands ready to contribute to efforts such as those above to encourage and support the development of national, State, Tribal, and community solutions using national data and benchmarks in disparities. We hope that the progress and gaps outlined in this NHDR will help policymakers ensure that all patients receive the health care they need to make their lives better.